Adult Medical Emergency Handbook - Scottish Intensive Care Society

abnormalities develop i.e. second or third degree AV block a permanent
pacemaker is indicated prior to discharge. New left bundle branch block
associated with first degree heart block should be treated similarly.
INTRA-AORTIC BALLOON PUMP (IABP)
May be useful in severe acute valvular disease, in severe unstable
angina or in cardiogenic shock. Prior to insertion there should be a
clearly agreed clinical management strategy. Discuss with senior
cardiologist.
SPECIFIC DRUG POINTS
A full account of all drugs mentioned in the schedule is available in the BNF,
which should be consulted. Further detail in CCU Therapeutic Schedule.
ACE-INHIBITORS
Reduce mortality after AMI by approximately 20-30%.
Most frequently used drugs: ramipril, lisinopril, enalapril.
• Following AMI, therapy is normally commenced when the patient
is stable, within 24-36 hours after the acute event.
• Where significant hypotension might occur (e.g. pre-existing
hypotension, reno-vascular disease), a test dose of captopril
6.25mg is normally used. The blood pressure and pulse should be
monitored every 30 minutes for 2 hours following this.
• Where hypotension is unlikely to be a problem, low dose ramipril,
lisinopril or enalapril are equally appropriate as initial therapy.
• It is important to titrate ACE inhibitors to appropriate doses
as used in clinical trials - lisinopril 10mg od, ramipril 5mg bd
(especially if signs of heart failure present), enalapril 10-20mg bd.
• Effects of potassium supplements or potassium sparing diuretics
should be monitored closely by checking plasma potassium and
adjusting prescription accordingly.
BETA BLOCKERS
Reduce mortality after AMI by ~25%
• Contra-indicated in asthma.
• Prescribe with caution in COPD.
• Stable chronic peripheral vascular disease is NOT a contra-indication.
• Beta blockers should also be considered in patients with heart
failure associated with AMI once stabilised.
128 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2009/11